Choice architecture as a means to change eating behaviour in self-service settings: a systematic review

Who chooses "healthy" meals? An analysis of lunchtime meal quality in a workplace cafeteria

BACKGROUND

The workplace can play an important role in shaping the eating behaviors of U.S. adults. Unfortunately, foods obtained in the workplace tend to be low in nutritional quality. Questions remain about the best way to approach the promotion of healthy food purchases among employees and to what extent health promotion activities should be tailored to the demographic characteristics of the employees. The purpose of this study was to (1) assess the nutritional quality of lunchtime meal purchases by employees in cafeterias of a large organization, (2) examine associations between lunchtime meal quality selection and the demographic characteristics of employees, and (3) determine the healthfulness of foods and beverages offered in the cafeterias of this organization.

METHODS

A cross-sectional analysis was conducted using secondary data from a food labeling study implemented in three worksite cafeterias. Demographic data was collected via surveys and meal data was collected using a photo capture system for 378 participants. The Healthy Eating Index 2015 (HEI-2015) was used to determine meal quality and a total score for the menu of options available in the cafeterias during the study period. Summary statistics were generated, and the analysis of variance (ANOVA) was used to compare the HEI-2015 scores between groups.

RESULTS

The mean HEI-2015 total score for the menu items offered (n = 1,229) in the cafeteria during the study period was 63.1 (SD = 1.83). The mean HEI-2015 score for individual lunchtime meal observations (n = 378) was 47.1 (SD = 6.8). In general, HEI-2015 total scores were higher for non-smokers, individuals who self-identified as Asian, had higher physical activity levels, scored higher on numeracy and literacy assessments, and reported higher education levels, incomes, and health status.

CONCLUSIONS

The overall HEI-2015 scores indicate that the menu of options offered in the cafeterias and individual meal selections did not align with the Dietary Guidelines for Americans, and there were significant associations between average lunchtime meal quality scores and several demographic characteristics. These results suggest that healthy eating promotion activities in workplaces may need to be tailored to the demographic characteristics of the employees, and efforts to improve the food environment in the workplace could improve meal quality for all employees.

The impact of nutritional labeling on adult snack choices: A controlled field experiment in a non-commercial professional setting

Each year, 2.8 million people die because of comorbidities associated with being overweight. Snacking substantially contributes to people's calorie intake. One way to nudge consumers towards healthier alternatives is the implementation of nutritional labeling. This study reports on a controlled field experiment that evaluates the effect of two nutritional labels on free snack choices (n = 739). Participants at a conference could choose between nuts, cookies, and candy bars as a snack, presented at the bar at six different locations across 2 bar counters. The labels were set up in front of each snack in three conditions: no labeling (control), a calorie label, or a traffic light label (i.e., the Nutri-Score). The location of the snacks on the counter (Either side of the counter; Center, Right, Left) and the time-of-day (Morning (=reference) vs Afternoon) were statistically controlled for. The results show that calorie labels could not successfully nudge consumers toward healthier snack choices (nuts instead of candy bars or cookies). In contrast, the Nutri-Score label significantly increased the probability of choosing nuts over candy bars. The Nutri-Score also increased the chance of choosing nuts over cookies, but the difference was not significant. No prior studies to our knowledge have directly compared calorie labels to the Nutri-Score. This study suggests that the Nutri-Score label can be a more successful intervention than calorie labels to nudge consumers towards healthier choices in situations were free snacks are offered, like many modern workplaces. Changing snacking behavior is challenging and naturalistic field experiments like this one are needed to translate the theory from previous laboratory studies to real-life settings.

Evaluation of an Environmental Nutrition Intervention at the 2018 Commonwealth Games

There has been an increasing expectation that the food provided for athletes at major competition events meets the specific dietary and performance needs of athletes. The aim of this study was to map the range of food service nutrition schemes that were implemented prior to and during a major competition event (2018 Commonwealth Games) and evaluate these schemes through staff training satisfaction, athlete feedback, and quality assurance checks. This study followed a case study design with nutrition schemes as follows: informing (nutrition labelling), enabling (staff training, nutrition service), and engineering (modification to menus and recipes). Overall, participants reported that they easily found items on the menu that met their nutritional/dietary needs. When asked how useful the schemes were in helping them to identify items that meet their needs, the majority of participants found the nutrition cards (n = 227, 71%) and serving staff (n = 212, 66%) 'useful/very useful'. 'Good/very good' ratings were received by >90% of respondents for speed of service, staff politeness, and knowledge of the menu. Participants (n = 316) who rated the nutrition staff as 'useful/very useful' gave a higher median rating for the menu. Past events have focused on the impact of a single component in the food environment; however, taking a whole systems approach resulted in more suitable food provision to meet the dietary needs of athletes.

Creating healthy food environments in recreation and sport settings using choice architecture: a scoping review

Recreation and sport settings (RSS) are ideal for health promotion, however, they often promote unhealthy eating. Choice architecture, a strategy to nudge consumers towards healthier options, has not been comprehensively reviewed in RSS and indicators for setting-based multi-level, multi-component healthy eating interventions in RSS are lacking. This scoping review aimed to generate healthy food environment indicators for RSS by reviewing peer-reviewed and grey literature evidence mapped onto an adapted choice architecture framework. One hundred thirty-two documents were included in a systematic search after screening. Data were extracted and coded, first, according to Canada's dietary guideline key messages, and were, second, mapped onto a choice architecture framework with eight nudging strategies (profile, portion, pricing, promotion, picks, priming, place and proximity) plus two multi-level factors (policy and people). We collated data to identify overarching guiding principles. We identified numerous indicators related to foods, water, sugary beverages, food marketing and sponsorship. There were four cross-cutting guiding principles: (i) healthy food and beverages are available, (ii) the pricing and placement of food and beverages favours healthy options, (iii) promotional messages related to food and beverages supports healthy eating and (iv) RSS are committed to supporting healthy eating and healthy food environments. The findings can be used to design nested, multipronged healthy food environment interventions. Future research is needed to test and systematically review the effectiveness of healthy eating interventions to identify the most promising indicators for setting-based health promotion in RSS.

Position statement on nutrition therapy for overweight and obesity: nutrition department of the Brazilian association for the study of obesity and metabolic syndrome (ABESO-2022)

Obesity is a chronic disease resulting from multifactorial causes mainly related to lifestyle (sedentary lifestyle, inadequate eating habits) and to other conditions such as genetic, hereditary, psychological, cultural, and ethnic factors. The weight loss process is slow and complex, and involves lifestyle changes with an emphasis on nutritional therapy, physical activity practice, psychological interventions, and pharmacological or surgical treatment. Because the management of obesity is a long-term process, it is essential that the nutritional treatment contributes to the maintenance of the individual's global health. The main diet-related causes associated with excess weight are the high consumption of ultraprocessed foods, which are high in fats, sugars, and have high energy density; increased portion sizes; and low intake of fruits, vegetables, and grains. In addition, some situations negatively interfere with the weight loss process, such as fad diets that involve the belief in superfoods, the use of teas and phytotherapics, or even the avoidance of certain food groups, as has currently been the case for foods that are sources of carbohydrates. Individuals with obesity are often exposed to fad diets and, on a recurring basis, adhere to proposals with promises of quick solutions, which are not supported by the scientific literature. The adoption of a dietary pattern combining foods such as grains, lean meats, low-fat dairy, fruits, and vegetables, associated with an energy deficit, is the nutritional treatment recommended by the main international guidelines. Moreover, an emphasis on behavioral aspects including motivational interviewing and the encouragement for the individual to develop skills will contribute to achieve and maintain a healthy weight. Therefore, this Position Statement was prepared based on the analysis of the main randomized controlled studies and meta-analyses that tested different nutrition interventions for weight loss. Topics in the frontier of knowledge such as gut microbiota, inflammation, and nutritional genomics, as well as the processes involved in weight regain, were included in this document. This Position Statement was prepared by the Nutrition Department of the Brazilian Association for the Study of Obesity and Metabolic Syndrome (ABESO), with the collaboration of dietitians from research and clinical fields with an emphasis on strategies for weight loss.

Nutrition Program Fidelity Assessment tool: a framework for optimising implementation in military dining facilities

OBJECTIVE

The aim was to develop, refine and assess the usefulness of the Go for Green® (G4G) 2.0 Program Fidelity Assessment (PFA) tool. G4G 2.0 is a Department of Defense programme designed to optimise access, availability and knowledge of high-performance nutritious foods in military dining facilities (DFAC).

DESIGN

During a multi-site study to evaluate G4G 2.0 on meal quality and diner satisfaction, subject matter experts developed and refined a PFA tool based on eight programme requirements (PR). They identified tasks critical to programme success and corresponding benchmarks, then proposed expansion of several PR and developed a scoring system to assess adherence. Three PFA were conducted (Site 1, Site 2A and Site B).

SETTING

Two DFAC in the USA implementing the G4G 2.0 programme.

PARTICIPANTS

Military DFAC participating in a G4G 2.0 evaluation study.

RESULTS

After G4G 2.0 implementation, Site 1 conducted a PFA and met benchmarks for eight of fifteen sections. At Site 2, a PFA was conducted after G4G 2.0 implementation (Site 2A) and one 3 months later (Site 2B) with twelve of fifteen and ten of fifteen sections meeting benchmarks, respectively.

CONCLUSION

Research highlights the need to maximise implementation quality to ensure interventions are effective, achievable and efficient. Using a PFA tool to objectively assess nutrition interventions can inform programme fidelity, successes and opportunities for improvement. Results identify key areas that require additional training and resources to optimise access to nutrient-dense foods that support nutritional fitness. This feedback is critical for assessing potential programme impact on Service Members.

Effectiveness of a Multi-Strategy Behavioral Intervention to Increase Vegetable Sales in Primary School Canteens: A Randomized Controlled Trial

Children’s vegetable intake remains inadequate and school canteens may provide opportunities to address this public health concern. This study aimed to determine the effectiveness of an 8-week multi-strategy behavioral intervention that included vegetable provisioning and online menu architecture on vegetable sales in primary school canteens. A randomized controlled trial was undertaken in 16 Australian primary schools (n = 4302 students). The control arm kept their regular canteen menu. The primary outcome was vegetable sales measured by assessing vegetable content (in grams) from all menu items and using canteen sales (ordered online and over-the-counter) to calculate vegetable sales (in grams/week) at baseline (3 weeks) and during intervention implementation (8 weeks). Secondary outcomes were vegetable sales in subcategories, intervention acceptability among canteen managers and vegetable waste (four schools). Linear mixed model analysis showed that from baseline to follow-up, the intervention group had significantly higher weekly vegetable sales overall compared with the control group (2707 g/week, 95% CI 1276 to 4137 g/week; p < 0.001), with increased vegetable sales in the subcategories of burgers, hot foods and snacks, but not in sandwiches and pasta/rice dishes. The intervention did not lead to more vegetable waste, nor to a decrease in canteen revenue. The canteen managers found the intervention easy to implement and felt children responded favorably to three of the seven strategies. In conclusion, a multi-strategy behavioral canteen intervention increased vegetable sales amongst primary school students.

Nudging food service users to choose fruit- and vegetable-rich items: Five field studies

Although nudging has been found to promote the choice of healthy foods in lab studies and ad-hoc field studies, relatively little research is available regarding effectiveness in real food venues that operate for profit. The paucity of empirical studies providing "proof of implementation" reveals the difficulty of applying previous empirical findings on nudging to mass-eating food services contexts, which serve meals to a lot of individuals daily. Based on the typology of choice architecture in food choice contexts, we closely collaborated with the in-house food service operator to devise and implement five nudge interventions to promote fruits and vegetables (FV) in university cafeterias. Each study was conducted for one 12-week semester or more over a three-year period. In the first two studies, non-verbal point-of-purchase prompting increased the choice of kale/spinach supplemented smoothies and whole fruits from baskets. In Study 3, the combination of sizing and point-of-purchase non-verbal prompting increased the sale of large size vegetable-rich bowls from a stir-fry grill. In Study 4, the proximity type of nudging by altering the position of the healthier option in a sandwich bar in combination with non-verbal prompting increased the sale of sandwiches containing spinach. In Study 5, the combination of sizing and proximity of large vs. small sized plates and serving spoons had no effect on sale of self-serve items in a salad bar. All the interventions except for Study 5 produced a moderate effect in increasing the choice of FV-rich items. We recommend that hospitality and food service operators consider operational parameters and simultaneously adopt more than one nudging components to achieve a sizable effect. Future randomized controlled trials are needed to implement choice architecture techniques in collaboration with food service companies.

Long-term Effectiveness of a Multistrategy Behavioral Intervention to Increase the Nutritional Quality of Primary School Students' Online Lunch Orders: 18-Month Follow-up of the Click & Crunch Cluster Randomized Controlled Trial

Background

School food services, including cafeterias and canteens, are an ideal setting in which to improve child nutrition. Online canteen ordering systems are increasingly common and provide unique opportunities to deliver choice architecture strategies to nudge users to select healthier items. Despite evidence of short-term effectiveness, there is little evidence regarding the long-term effectiveness of choice architecture interventions, particularly those delivered online.

Objective

This study determined the long-term effectiveness of a multistrategy behavioral intervention (Click & Crunch) embedded within an existing online school lunch-ordering system on the energy, saturated fat, sugar, and sodium content of primary school students’ lunch orders 18 months after baseline.

Methods

This cluster randomized controlled trial (RCT) involved a cohort of 2207 students (aged 5-12 years) from 17 schools in New South Wales, Australia. Schools were randomized to receive either a multistrategy behavioral intervention or the control (usual online ordering only). The intervention strategies ran continuously for 14-16.5 months until the end of follow-up data collection. Trial primary outcomes (ie, mean total energy, saturated fat, sugar and sodium content of student online lunch orders) and secondary outcomes (ie, the proportion of online lunch order items that were categorized as everyday, occasional, and caution) were assessed over an 8-week period at baseline and 18-month follow-up.

Results

In all, 16 schools (94%) participated in the 18-month follow-up. Over time, from baseline to follow-up, relative to control orders, intervention orders had significantly lower energy (–74.1 kJ; 95% CI [–124.7, –23.4]; P=.006) and saturated fat (–0.4 g; 95% CI [–0.7, –0.1]; P=.003) but no significant differences in sugar or sodium content. Relative to control schools, the odds of purchasing everyday items increased significantly (odds ratio [OR] 1.2; 95% CI [1.1, 1.4]; P=.009, corresponding to a +3.8% change) and the odds of purchasing caution items significantly decreased among intervention schools (OR 0.7, 95% CI [0.6, 0.9]; P=.002, corresponding to a –2.6% change). There was no between-group difference over time in canteen revenue.

Conclusions

This is the first study to investigate the sustained effect of a choice architecture intervention delivered via an online canteen ordering systems in schools. The findings suggest that there are intervention effects up to 18-months postbaseline in terms of decreased energy and saturated fat content and changes in the relative proportions of healthy and unhealthy food purchased for student lunches. As such, this intervention approach may hold promise as a population health behavior change strategy within schools and may have implications for the use of online food-ordering systems more generally; however, more research is required.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618000855224; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375075

The nutriRECIPE-Index - development and validation of a nutrient-weighted index for the evaluation of recipes

Background

Our objective was to develop a nutrient-based index for evaluating and improving menus in public catering. The nutriRECIPE-Index comprises 24 nutrients and nutrient groups. In developing the index, the following steps were included: setting the goals of the index, nutrient selection, target metrics and scaling, weighting, proof of concept and validation of the index. Furthermore, a unique database was created to integrate bioactive plant compounds in the assessment. An assessment of standard recipes and supposedly healthy recipes should show a significant difference in the results of the nutriRECIPE-Index. Finally, the nutriRECIPE-Index should generate similar or more specific results than existing indices such as the Nutri-Score and the Healthy Meal Index.

Methods

A whole meal cycle (comprising 6 weeks, 106 recipes and including different menu lines, partially with different side dishes) at a university canteen was analysed with the Federal Food Code (BLS) and the nutriRECIPE-Index. The Healthy Meal Index (comprising 3 nutritionally relevant items) and the Nutri-Score algorithm (comprising 7 items) were used to validate the nutrient composition and the results of the nutriRECIPE-Index.

Results

The resulting scores of the recipes and menu lines showed substantial differences, wherein the meals of a health-promoting menu line usually received higher scores than the standard recipes. A correlation between the nutriRECIPE-Index and the Healthy Meal Index (0.604) and the Nutri-Score (0.591) was observed. The nutriRECIPE-Index was better at identifying the worst menus and could better separate mediocre menus from good menus.

Conclusion

The nutriRECIPE-Index is a useful and comprehensive tool for evaluating the nutritional value of recipes and is the first to consider bioactive plant compounds. Further adjustments to different target populations, settings, and cultural backgrounds are possible.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-021-00483-7.

Why We Eat the Way We Do: A Call to Consider Food Culture in Public Health Initiatives

The way we eat has changed dramatically in only a few decades. While definitions of food culture have previously existed, a clear description of modern food culture that can be used for health promotion is lacking. In this paper, we propose a concept of food culture for application within public health, what a positive food culture looks like compared to negative elements that have dominated in developed countries and the consequences for physical and mental health and wellbeing. We support calls to action from the international community to reconsider the way we eat. All segments of society have a role to play in building a positive food culture, and it is critical that macro (policy and systems) and meso (community) level environmental factors align and provide supportive environments that promote health-enhancing behaviours. Defining food culture is a necessary step towards articulating the complexities that influence food behaviours and impact health. The ultimate goal is collective action to enable population-wide and sustained improvements to the way we eat, and how we think and feel about food.

Strategies to Improve School Meal Consumption: A Systematic Review

School meals can play an integral role in improving children's diets and addressing health disparities. Initiatives and policies to increase consumption have the potential to ensure students benefit from the healthy school foods available. This systematic review evaluates studies examining initiatives, interventions, and policies to increase school meal consumption. Following PRISMA guidelines, this review was conducted using four databases and resulted in a total of 96 studies. The research evidence supports the following strategies to increase school meal consumption: (1) offering students more menu choices; (2) adapting recipes to improve the palatability and/or cultural appropriateness of foods; (3) providing pre-sliced fruits; (4) rewarding students who try fruits and vegetables; (5) enabling students to have sufficient time to eat with longer (~30 min) lunch periods; (6) having recess before lunch; and (7) limiting students' access to competitive foods during the school day. Research findings were mixed when examining the impact of nutrition education and/or offering taste tests to students, although multiple benefits for nutrition education outside the cafeteria were documented. There is some evidence that choice architecture (i.e., "Smarter Lunchroom") techniques increase the proportion of students who select targeted meal components; however, there is not evidence that these techniques alone increase consumption. There were limited studies of the impact of increasing portion sizes; serving vegetables before other meal components; and strengthening local district and/or school wellness policies, suggesting that further research is necessary. Additionally, longer-term studies are needed to understand the impact of policies that limit students' access to flavored milk. Several studies found increases in students' meal consumption following the Healthy Hunger-Free Kids Act (HHFKA) and concerns regarding an increase in food waste following the HHFKA were not supported. Overall, there are a range of effective strategies to increase school meal consumption that can be implemented by schools, districts, and policymakers at the local, state, and federal levels (PROSPERO registration: CRD42021244688).

Post-Secondary Food Service Manager Perspectives on Fruit and Vegetable Nudging Strategies: Qualitative Study

BACKGROUND

Changing the choice architecture in post-secondary food service contexts to "nudge" customers to choose more fruits and vegetables (FV) shows promise in intervention studies to date. If such approaches are to become more widely adopted, they must be feasible and acceptable to food service managers. Among possible early adopters, managers of food services in post-secondary education institutions may have unique insights on implementation of such approaches, as they have dual mandates to support student health and maintain profitability.

OBJECTIVE

The goal of this exploratory study was to examine current knowledge, practice, facilitators, and barriers to uptake of nudge strategies promoting FV in a sample of post-secondary food service managers.

METHODS

A qualitative telephone interview study was undertaken with food service managers across Canada (n = 10 institutions), recruited from a national professional organization. One or more representatives from each institution completed the interview. Interviews were audio-recorded, transcribed, and underwent framework descriptive and interpretative content analysis in NVivo (QSR International). Münscher's Taxonomy of Choice Architecture and the Ottawa Model for Research Use guided development and analysis.

RESULTS

Managers from 9 universities and 1 technical college participated. Local context, governance, and resources varied widely. Eight of 10 institutions used some form of FV nudging as part of their marketing and health promotion, most commonly to reduce the effort associated with choosing FV. Nudging strategies aimed at increasing the range and composition of FV offerings, providing a social reference (opinion leaders) for choosing FV, and changing consequences with loyalty cards were also common. Other nudging strategies were used infrequently. Cost, operational ease of implementation, and students' privacy and choices were critical issues in adoption.

CONCLUSIONS

The results can inform development and testing of locally adapted nudge interventions. It is critical that managers be involved from the outset of any planned academic implementation study.

The Effectiveness of Interventions Delivered Using Digital Food Environments to Encourage Healthy Food Choices: A Systematic Review and Meta-Analysis

Digital food environments are now commonplace across many food service and retail settings, influencing how the population orders and accesses foods. As such, digital food environments represent a novel platform to deliver strategies to improve public health nutrition. The purpose of this review was to explore the impact of dietary interventions embedded within online food ordering systems, on user selection and purchase of healthier foods and beverages. A systematic search of eight electronic databases and grey literature sources was conducted up to October 2020. Eligible studies were randomized controlled trials and controlled trials, designed to encourage the selection and purchase of healthier products and/or discourage the selection and purchase of less-healthy products using strategies delivered via real-world online food ordering systems. A total of 9441 articles underwent title and abstract screening, 140 full-text articles were assessed for eligibility, and 11 articles were included in the review. Meta-analysis of seven studies indicated that interventions delivered via online food ordering systems are effective in reducing the energy content of online food purchases (standardized mean difference (SMD): -0.34, p = 0.01). Meta-analyses including three studies each suggest that these interventions may also be effective in reducing the fat (SMD: -0.83, p = 0.04), saturated fat (SMD: -0.7, p = 0.008) and sodium content (SMD: -0.43, p = 0.01) of online food purchases. Given the ongoing growth in the use of online food ordering systems, future research to determine how we can best utilize these systems to support public health nutrition is warranted.

Nudging healthy and sustainable food choices: three randomized controlled field experiments using a vegetarian lunch-default as a normative signal

BACKGROUND

This study investigates a simple, generic and easily scalable nudge to promote healthy and sustainable food choices at conferences by using a vegetarian lunch-default as a normative signal.

METHODS

At three conferences, participants registering electronically were randomized into two groups: Group 1 received a standard lunch registration presenting a non-vegetarian buffet as the default, but allowing the active choice of a vegetarian option; Group 2 received a registration presenting a vegetarian buffet as the default, allowing the active choice of a non-vegetarian option. The study also assessed gender differences for two of the conferences and the participants' acceptance of the nudge at one of the conferences.

RESULTS

In experiment A the vegetarian choice increased from 2% to 87% (N = 108, P < 0.001). In experiment B it increased from 6% to 86% (N = 112, P < 0.001). In experiment C it increased from 12.5% to 89% (N = 110, P < 0.001). A significant tendency for men, but not women, to opt out of the vegetarian default was found and a clear majority of participants reported positive attitudes toward the nudge.

CONCLUSIONS

Changing the lunch-default to a vegetarian option is an effective, generic, easy to scale and well-accepted nudge to promote healthy and sustainable food choices at conferences.

Consumer expectation and responses to environmental sustainability initiatives and their impact in foodservice operations: A systematic review

BACKGROUND

With increasing pressure on the Earth's finite resources, there is significant demand for environmentally sustainable practices in foodservice. A shift to sustainable foodservice operations can decrease its environmental impact and may align with consumer expectations. This systematic review explored consumer expectations (attitudes pre-intervention) and responses (behaviour, cognitive attitudes and affective attitudes post-intervention) towards environmentally sustainable initiatives of foodservice operations.

METHODS

A systematic search following PRISMA guidelines was conducted across MEDLINE, EMABASE, CINAHL and Web of Science databases. English and full-text research articles published up to November 2019 were identified. Consumers' expectations and responses to interventions were extracted. The quality of the studies was assessed using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Thirty-three studies were included and, given the heterogeneity of the studies, the results were synthesised narratively. The main outcomes analysed included changes in behaviour and attitudes (cognitive and affective), including knowledge and satisfaction. Intervention strategies were interpreted and categorised into three groups: food waste reduction, single-use item and packaging waste reduction, and initiatives related to menu, messaging and labelling. Most studies resulted in significant pro-environmental changes towards decreasing food waste, decreasing single use-item and packaging waste, as well as engaging consumers in sustainable eating.

CONCLUSIONS

There are a range of successful environmentally sustainable strategies that when implemented by foodservices can have a mostly positive impact on consumer attitudes and responses. However, positive consumer attitudes did not always translate to changes in behaviour. Foodservices should carefully consider implementing interventions that support changes in consumer behaviour.

Evaluation of the Small Changes, Healthy Habits Pilot Program: Its Influence on Healthy Eating and Physical Activity Behaviors of Adults in Louisiana

The community-based Small Changes, Healthy Habits (SCHH) program was developed to teach skills and techniques to help adults in Louisiana make and maintain small behavioral changes in their food selection, preparation, and consumption, and in physical activity routines. The content of this four-week program included habit formation and goal setting techniques; physical activity guidance; strategies for a healthier home food environment; a grocery store tour focused on label reading for healthier food selections; basic knife and cooking skills. The program was piloted at ten sites throughout the state. A survey with 14 core items was applied before and after the program to evaluate participant acquisition of skills and behaviors associated with topic areas. A total of 47 participants provided complete data sets. Post-program, these participants reported increased confidence in preparing healthy meals at home (p = 0.04); changes in fats (p = 0.03) and salt (p = 0.01) intake; increased frequency of reading nutrition labels (32%); decreased frequency of meals eaten outside the home (Improvement Index = 0.27); and decreased time/day spent sitting (p < 0.05). These short-term results suggest that the SCHH program has potential to positively affect healthy eating and to reduce sedentary behaviors, both of which are fundamental to good health and wellness.

Creating supportive eating places: a systematic review of food service initiatives

Obesity and diet-related health problems are complex, multi-factorial issues. Individual food choices are shaped by the wider context, and food environment level change is needed to support individual behaviour change. The food service sector can play an integral role, changing aspects of the food environment and contributing to improved consumer health. This systematic review aimed to analyse food service schemes that aimed to improve consumer health. Ten electronic databases were systematically searched to identify articles, supplemented with checking of reference lists from similar reviews and forward and backward searches to identify articles describing food service sector schemes. Sixteen schemes were identified, documented in 36 articles/reports. The schemes aimed to improve consumer health through one of three approaches-informing, enabling or engineering. In this order, these approaches involved increasing levels of effort from food services, corresponding with decreasing levels of effort for consumers. Half the schemes were informing, relying on an informed consumer to make a healthy choice. Most informing schemes had been evaluated to determine their impact on consumer choice and/or health, the evidence showed these schemes were generally ineffective. The effect of the enabling or engineering schemes on consumer choice and health had not been measured. Instead, evaluations focussed on process or business engagement rather than behavioural change assessments. This review indicates the food sector has the potential to contribute to consumer health through enabling and engineering; however, detailed outcome assessments are needed to draw definitive conclusions.

Interventions using behavioural insights to influence children's diet-related outcomes: A systematic review

The global prevalence of children with overweight and obesity continues to rise. Obesity in childhood has dire long-term consequences on health, social and economic outcomes. Promising interventions using behavioural insights to address obesity in childhood have emerged. This systematic review examines the effectiveness and health equity implications of interventions using behavioural insights to improve children's diet-related outcomes. The search strategy included searches on six electronic databases, reference lists of previous systematic reviews and backward searching of all included studies. One-hundred and eight papers describing 137 interventions were included. Interventions using behavioural insights were effective at modifying children's diet-related outcomes in 74% of all included interventions. The most promising approaches involved using incentives, changing defaults and modifying the physical environment. Information provision alone was the least effective approach. Health equity implications were rarely analysed or discussed. There was limited evidence of the sustainability of interventions-both in relation to their overall effectiveness and cost-effectiveness. The limited evidence on health equity, long-term effectiveness and the cost-effectiveness of these interventions limit what can be inferred for policymakers. This review synthesises the use of behavioural insights to improve children's diet-related outcomes, which can be used to inform future interventions.

Pilot Study of a Farm-to-Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Intervention Promoting Vegetable Consumption

BACKGROUND

Vegetable intake is below recommended levels among adults served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

OBJECTIVE

The aim of this study was to determine whether a novel, theory-driven, farm-to-WIC intervention to promote vegetable intake showed promise of being successful and is therefore appropriate for efficacy testing.

DESIGN

From June 2019 to January 2020, the intervention was piloted in three WIC agency sites (one randomized to the intervention study group and two to the control group) selected based on similarity in size and the demographics of participants served.

PARTICIPANTS/SETTING

Recruited between June 3, 2019 and August 1, 2019, participants were 297 primarily Hispanic adults served by a large WIC agency located in a densely populated urban area in New Jersey (160 were enrolled at the intervention site and 137 at control sites).

INTERVENTION

The intervention combined behaviorally focused instruction and handouts with the introduction of a WIC-based farmers' market, field trips to an area farmers' market, telephone coaching and support before and after trips, and recipe demonstrations and tastings.

MAIN OUTCOME MEASURES

The primary outcomes were vegetable intake (measured objectively using dermal carotenoids as a biomarker of intake and via self-report) and the redemption of vouchers provided through the WIC Farmers' Market Nutrition Program (FMNP) for fruit and vegetable purchases at farmers' markets (objectively assessed using data provided by WIC).

STATISTICAL ANALYSES PERFORMED

Between-group differences in vegetable intake were examined at mid- and post-intervention (3 and 6 months post-baseline, respectively) with linear mixed-effects models adjusted for baseline vegetable intake and covariates. Logistic regression analysis was used to relate FMNP voucher redemption to study group and covariates.

RESULTS

At mid-intervention, objectively measured vegetable intake was higher among participants in the control group as compared with the intervention group; self-reported intake did not differ by group. Post-intervention, objectively measured and self-reported vegetable intake were higher among participants in the intervention group as compared with the control group. Receipt of the intervention was associated with a greater likelihood of FMNP voucher redemption. Voucher redemption rates were 87% in the intervention group and 28% in the control group (odds ratio = 17.39, 95% confidence interval [8.64, 35.02]).

CONCLUSIONS

Meaningful associations found between the intervention, vegetable intake, and FMNP voucher redemption suggest that the program is appropriate for efficacy testing.

A nudge in the right direction: the role of food choice architecture in changing populations' diets

Populations' diets typically fall short of recommendations. The implication of this on ill health and quality of life is well established, as are the subsequent health care costs. An area of growing interest within public health nutrition is food choice architecture; how a food choice is framed and its influence on subsequent food selection. In particular, there is an appeal to manipulating the choice architecture in order to nudge individuals' food choice. This review outlines the current understanding of food choice architecture, theoretical background to nudging and the evidence on the effectiveness of nudge strategies, as well as their design and implementation. Interventions emphasising the role of nudge strategies have investigated changes to the accessibility, availability and presentation of food and the use of prompts. Empirical studies have been conducted in laboratories, online and in real-world food settings, and with different populations. Evidence on the effectiveness of nudge strategies in shifting food choice is encouraging. Underpinning mechanisms, not yet fully explicated, are proposed to relate to salience, social norms and the principle of least effort. Emerging evidence points to areas for development including the effectiveness of choice architecture interventions with different and diverse populations, and the combined effect of multiple nudges. This, alongside further examination of theoretical mechanisms and guidance to engage and inspire across the breadth of food provision, is critical. In this way, the potential of choice architecture to effect meaningful change in populations' diets will be realised.

Spontaneous Variety-Seeking Meal Choice in Business Canteens Impedes Sustainable Production

Sustainable meal choices in the out-of-home catering market are essential to attaining the Sustainable Development Goals. This study investigated consumers’ acceptance of different features that help service providers to work more sustainably. For this purpose, data of a choice experiment and a supporting online questionnaire were analyzed using latent class analysis (LCA) and the data of n = 373 employees. Examined attributes in the choice experiment were menu variety, menu type, ordering system, ingredients and price. LCA led to four consumer segments: variety seekers (27.6%), spontaneous decisionmakers—vegetarian (25.7%), spontaneous decisionmakers—meat (24.1%) and vegetarians/vegans (22.6%). Results showed that consumers in all four segments expected to have the choice between different menus in company canteens. Moreover, they preferred spontaneous choice to preordering. Both preferences hamper sustainable production and consumption in the catering sector.

Nudging healthier food choices in a cafeteria setting: A sequential multi-intervention field study

Creating more health-fostering environments is high on the agenda of public and private actors. The behavioral approach to nudge people towards healthier food choices is gaining popularity despite limited understanding about where, and for whom, which specific nudges work. This study contributes by reporting on three different nudging interventions in the same setting and presents effects on different sub-populations. We find overall small effects that are heterogeneous, ranging from robustly more to even less healthy choices. We discuss the importance of transparency and reactance to health interventions and the potential interplay of interventions with habitual behavior among different sub-populations.

ImpulsePal: The systematic development of a smartphone app to manage food temptations using intervention mapping

BACKGROUND

Impulsive processes driving eating behaviour can often undermine peoples' attempts to change their behaviour, lose weight and maintain weight loss.

AIM

To develop an impulse management intervention to support weight loss in adults.

METHODS

Intervention Mapping (IM) was used to systematically develop the "ImpulsePal" intervention. The development involved: (1) a needs assessment including a qualitative study, Patient and Public advisory group and expert group consultations, and a systematic review of impulse management techniques; (2) specification of performance objectives, determinants, and change objectives; (3) selection of intervention strategies (mapping of change techniques to the determinants of change); (4) creation of programme materials; (5) specification of adoption and implementation plans; (6) devising an evaluation plan.

RESULTS

Application of the IM Protocol resulted in a smartphone app that could support reductions in unhealthy (energy dense) food consumption, overeating, and alcoholic and sugary drink consumption. ImpulsePal includes inhibition training, mindfulness techniques, implementation intentions (if-then planning), visuospatial loading, use of physical activity for craving management, and context-specific reminders. An "Emergency Button" was also included to provide access to in-the-moment support when temptation is strong.

CONCLUSIONS

ImpulsePal is a novel, theory- and evidence-informed, person-centred app that aims to support impulse management for healthier eating. Intervention Mapping facilitated the incorporation of app components that are practical operationalisations of change techniques targeting our specific change objectives and their associated theoretical determinants. Using IM enabled transparency and provided a clear framework for evaluation, and enhances replicability and the potential of the intervention to accomplish the desired outcome of facilitating weight loss through dietary change.

Robust statistical methods for point of sale designs, the example of healthcare snack and drink vending

Purpose

The experiment introduces nutritional labelling, healthier products and product placement designs to the hospital vending machines, to promote healthy lifestyles.

Design/methodology/approach

The site where this experiment happens is a major London hospital, serving over a million patients every year. In the experiment, the hospital’s snack and drink vending machines are redesigned. The impact on product sales are then analysed using robust statistical methods.

Findings

Nutritional labelling has a statistically significant impact on product sales. Less of the unhealthiest products are sold. Healthier products and product placement designs have a larger impact but with less statistical significance. They require further testing.

Research limitations/implications

Experts in service operations can use this experiment’s regression modelling methods. The methods are ideal for measuring change over time in counting data sets in complex real world environments.

Practical implications

There are suggestions for practical vending service change in this research. They are in line and add a practical example to Government policy guidance.

Social implications

People using the redesigned vending machines have more opportunity for healthy lifestyle choices.

Originality/value

The experiment provides statistical evidence in support of catering for healthier lifestyles.

Nudging healthy eating in Dutch sports canteens: a multi-method case study

OBJECTIVE

To provide a micro-investigation into the long-term effects and process of implementation of a nudge intervention on food choice in sports canteens.

DESIGN

Multi-method case study.

SETTING

Eight products were added to the range of foods and drinks in two football canteens in the Netherlands for 3 and 15 weeks, serving as a baseline period. In the intervention period, these products were promoted with the use of salience, scarcity, availability and default nudges, for 26 and 16 weeks, respectively. Aside from the collection of sales and revenue data, reach, acceptability, adherence and applicability were measured using observations, questionnaires and interviews.

PARTICIPANTS

Questionnaires were filled in by seventy and fifty-nine visitors of the canteens. Four interviews were held with board members and canteen personnel.

RESULTS

Mixed results were obtained regarding the suitability of nudges to be used to promote healthy eating in sports clubs. Sales and revenue data did show positive trends, the intervention was seen as acceptable by all stakeholders and the intervention had a large reach. However, adherence to the intervention in both canteens and the effects of the nudges on the total consumption pattern were low. Factors were identified that promoted or hindered the intervention at an individual, interventional and organisational level.

CONCLUSIONS

Nudges seem to be a valuable addition to other efforts to combat unhealthy eating. However, the extent of their impact as a single intervention tool is limited in the current food-abundant environment.

When in Doubt, Follow the Crowd? Responsiveness to Social Proof Nudges in the Absence of Clear Preferences

Nudges have gained popularity as a behavioral change tool that aims to facilitate the selection of the sensible choice option by altering the way choice options are presented. Although nudges are designed to facilitate these choices without interfering with people’s prior preferences, both the relation between individuals’ prior preferences and nudge effectiveness, as well as the notion that nudges ‘facilitate’ decision-making have received little empirical scrutiny. Two studies examine the hypothesis that a social proof nudge is particularly effective when people have no clear prior preference, either because people are indifferent (in a color-categorization task; Study 1, N = 255) or because people experience a choice conflict (making shopping decisions about meat products; Study 2, N = 97). Both studies employed a social proof nudge to steer participants’ choices. The potential facilitating effect of the nudge was tested using a mouse-tracker paradigm that implicitly assessed experienced uncertainty during decision-making. Results showed that the nudge was effective in steering participants’ decisions; the facilitation effect (i.e., reduced uncertainty regarding the decision) was only observed for conflicting preferences, but not under indifference. A better understanding of when and how nudges can influence individuals’ behavior may help in deciding whether nudges are an appropriate policy tool for changing particular undesirable behavior.

The effectiveness of behavioral economics-informed interventions on physician behavioral change: A systematic literature review

OBJECTIVE

Interventions informed by behavioral economics have the potential to change behaviors governed by underlying cognitive biases. This has been explored extensively for various use in healthcare including changing patient behavior and, more recently, physician behavior. We aimed to systematically review the literature on the use and effectiveness of behavioral economics-informed interventions in changing physician behavior.

METHOD

We searched Medline, Cochrane Library, EBM Reviews, PsychINFO, EconLit, Business Source Complete and Web of Science for peer-reviewed studies published in English that examined the effectiveness of behavioral economics-informed interventions on physician behavioral change. We included studies of physicians in all care settings and specialties and all types of objectively measured behavioral outcomes. The reporting quality of included studies was appraised using the Effective Public Health Practice Project tool.

RESULTS

We screened 6,439 studies and included 17 studies that met our criteria, involving at least 9,834 physicians. The majority of studies were conducted in the United States, published between 2014 and 2018, and were in the patient safety and quality domain. Reporting quality of included studies included strong (n = 7), moderate (n = 6) and weak (n = 4). Changing default settings and providing social reference points were the most widely studied interventions, with these studies consistently demonstrating their effectiveness in changing physician behavior despite differences in implementation methods among studies. Prescribing behavior was most frequently targeted in included studies, with consistent effectiveness of studied interventions.

CONCLUSION

Changing default settings and providing social reference points were the most frequently studied and consistently effective interventions in changing physician behavior towards guideline-concordant practices. Additional theory-informed research is needed to better understand the mechanisms underlying the effectiveness of these interventions to guide implementation.

Effect of Impulsivity Traits on Food Choice within a Nudging Intervention

Food choices are often driven by impulsive tendencies rather than rational consideration. Some individuals may find it more difficult resisting impulses related to unhealthy food choices, and low self-control and high impulsivity have been suggested to be linked to these behaviors. Recent shifts have been made towards developing strategies that target automatic processes of decision-making and focus on adjusting the environment, referred to as nudging interventions. Therefore, the purpose of this study was to investigate the effect of impulsivity traits on food choices within a nudging intervention (increased perceived variety). A total of 83 adults participated in an experimental study consisting of a self-service intelligent buffet. Impulsivity traits were measured using the UPPS-P impulsivity scale. General linear models were fitted to evaluate the effect of the five impulsivity traits on the difference of salad consumption (g) between the control and intervention situations. Results showed that impulsivity does not affect food choices in this nudging situation, suggesting that nudging works independently of the participant's impulsivity score. Results also showed a significantly higher consumption of salad in the nudging versus the control setting (17.6 g, p < 0.05), suggesting that nudging interventions can be effective in significantly increasing total vegetable consumption across the whole impulsivity scale.

The Effect of an Evaluative Label on Consumer Perception of Cheeses in Hungary

Traditional strategies (such as education, economic incentives or prohibitions) targeted at altering dietary habits only influence health-conscious consumers. Less health-conscious consumers are less capable of self-regulatory behavior, therefore they are more likely to be influenced through perception. The present study aimed to examine how external cues such as labeling affect the consumer's perception of foods. The paper includes a case study based on an experiment. In the experiment the same cheese was tested with four different types of labeling (labeled "conventional", "low salt", "low fat" and "low salt and low fat"). It was found that the health halo effect worked in the case of cheese testing. In spite of all the samples being identical, the healthy samples were associated with considerably less sensory pleasure. The use of labels by the producers resulted in exactly the opposite effect to that intended. The experiment confirmed the efficiency of the application of this type of behavior-oriented nudge.

When a Combination of Nudges Decreases Sustainable Food Choices Out-Of-Home-The Example of Food Decoys and Descriptive Name Labels

This paper reports results from three consecutive studies focusing on the comparison of the effectiveness of different nudges and their combinations to increase sustainable food choices out of the home. The nudges compared are the use of descriptive name labels (DNLs) for the most sustainable dish of a choice set (menu) and the decoy effect (DE), created by adding a less attractive decoy dish to a more attractive target dish with the goal of increasing the choice frequency of the target dish. In the literature, both nudges have been found to influence consumers’ choices. In the first study, six category names of sustainability indicators were deduced from a focus group. These were tested with 100 students to identify the most attractive DNLs. Study II, a randomized choice study (n = 420), tested the DE, the DNLs and a combination of the DNLs and the DE used on four different dishes in a university canteen. In study III, 820 guests of a business canteen voted during four weeks for the special meals of the following week (identical to the four choice sets displayed in study II). Results indicate that the combination of DNLs and the DE is not recommended for fostering sustainable food choices. Pure DNLs were more efficient in increasing the choice frequency of the more sustainable meal, whereas the decoy effect resulted in decreased choice frequencies. Regional and sustainable DNLs were favoured by consumers.

The (bitter) sweet taste of nudge effectiveness: The role of habits in a portion size nudge, a proof of concept study

Seemingly insignificant daily practices, such as sugar usage in tea, can have a great accumulated impact on societal issues, such as obesity. That is why these behaviours are often the target of nudge interventions. However, when these behaviours are performed frequently they may turn into habits that are difficult to change. The aim of the current study was to investigate whether a portion size nudge has the potential to work in accordance with (instead of against) existing habits. Specifically, it was tested whether a portion size nudge would be more effective in reducing the amount of sugar added to tea, when people have a strong habit of adding a fixed amount of teaspoons of sugar to a cup of tea. The study (N = 123) had a mixed factorial design with teaspoon size (reduced size vs. control) as a within-subject factor, and habit disruption context condition (hot tea vs. cold tea) as a between-subjects factor. A paired t-test indicated that this nudge reduced sugar intake on average by 27% within subjects. When the context allowed for automatic enactment of the habit, the effectiveness of this nudge was moderated by habit strength. Surprisingly, the nudge effect was actually less pronounced when people had a strong habit. Implications for effective nudge interventions are discussed.

Choice architecture interventions to change physical activity and sedentary behavior: a systematic review of effects on intention, behavior and health outcomes during and after intervention

BACKGROUND

Choice architecture interventions, which subtly change the environment in which individuals make decisions, can be used to promote behavior change. This systematic review aimed to summarize studies on micro-environmental choice architecture interventions that encouraged physical activity or discouraged sedentary behavior in adults, and to describe the effectiveness of those interventions on these behaviors - and on related intentions or health outcomes - in presence of the intervention and after removal of the intervention (i.e. post-intervention, regardless of the time elapsed).

METHODS

We systematically searched PubMed, Embase, PsycINFO and the Cochrane Library for (quasi) experimental studies published up to December 2019 that evaluated the effect of choice architecture interventions on physical activity and sedentary behavior, as well as on intentions and health outcomes related to physical activity/sedentary behavior. Studies that combined choice architecture techniques with other behavior change techniques were excluded. All studies were screened for eligibility, relevant data was extracted and two independent reviewers assessed the methodological quality using the QualSyst tool.

RESULTS

Of the 9609 records initially identified, 88 studies met our eligibility criteria. Most studies (n = 70) were of high methodologic quality. Eighty-six studies targeted physical activity, predominantly stair use, whereas two studies targeted sedentary behavior, and one targeted both behaviors. Intervention techniques identified were prompting (n = 53), message framing (n = 24), social comparison (n = 12), feedback (n = 8), default change (n = 1) and anchoring (n = 1). In presence of the intervention, 68% of the studies reported an effect of choice architecture on behavior, whereas after removal of the intervention only 47% of the studies reported a significant effect. For all choice architecture techniques identified, except for message framing, the majority of studies reported a significant effect on behavioral intentions or behavior in presence of the intervention.

CONCLUSIONS

The results suggest that prompting can effectively encourage stair use in adults, especially in presence of a prompt. The effectiveness of the choice architecture techniques social influence, feedback, default change and anchoring cannot be assessed based on this review. More (controlled) studies are needed to assess the (sustained) effectiveness of choice architecture interventions on sedentary behavior and other types of physical activity than stair use.

The effectiveness of nudges in improving the self-management of patients with chronic diseases: A systematic literature review

In this systematic literature review, we identify evidence on the effectiveness of nudges in improving the self-management of adults with chronic diseases and derive policy recommendations. We included empirical studies of any design published up to April 12^th, 2018. We synthesized the results of the studies narratively by comparing statistical significance and direction of different nudge types' effects on primary study outcomes. Lastly, we categorized the nudges according to their degree of manipulation and transparency. We identified 26 studies, where 13 were of high or moderate quality. The most commonly tested nudges were reminders, planning prompts, small financial incentives, and feedback. Overall, 8 of 9 studies with a high or moderate quality ranking, focused on self-management outcomes, i.e., physical activity, attendance, self-monitoring, and medication adherence, found that nudges had significant positive effects. However, only 1 of 4 studies of high or moderate quality, analyzing disease control outcomes (e.g., glycemic control), found that nudges had a significant positive effect for one intervention arm. In summary, this review demonstrates that nudges can improve chronic disease self-management, but there is hardly any evidence to date that these interventions lead to improved disease control. Reminders, feedback, and planning prompts appear to improve chronic disease self-management most consistently and are among the least controversial types of nudges. Accordingly, they can generally be recommended to policymakers.

Investigating business outcomes of healthy food retail strategies: A systematic scoping review

Large changes to food retail settings are required to improve population diet. However, limited research has comprehensively considered the business implications of healthy food retail strategies for food retailers. We performed a systematic scoping review to identify types of business outcomes that have been reported in healthy food retail strategy evaluations. Peer-reviewed and grey literature were searched. We identified qualitative or quantitative real-world food or beverage retail strategies designed to improve the healthiness of the consumer nutrition environment (eg, changes to the "marketing mix" of product, price, promotion, and/or placement). Eligible studies reported store- or chain-level outcomes for measures of commercial viability, retailer perspectives, customer perspectives, and/or community outcomes. 11 682 titles and abstracts were screened with 107 studies included for review from 15 countries. Overall item sales, revenue, store patronage, and customer level of satisfaction with strategy were the most frequently examined outcomes. There was a large heterogeneity in outcome measures reported and in favourability for retailers of outcomes across studies. We recommend more consistent reporting of business outcomes and increased development and use of validated and reliable measurement tools. This may help generate more robust research evidence to aid retailers and policymakers to select feasible and sustainable healthy food retail strategies to benefit population health within and across countries.

Cueing healthier alternatives for take-away: a field experiment on the effects of (disclosing) three nudges on food choices

Background

The current field experiment demonstrates the effectiveness of nudging to promote healthy food choices.

Methods

Three types of nudges were implemented at a take-away food vendor: 1) an accessibility nudge that placed fruits at the front counter; 2) a salience nudge that presented healthy bread rolls to be more visually attractive; and 3) a social proof nudge that conveyed yoghurt as a popular choice. We additionally assessed whether nudging effects would remain robust when a disclosure message was included. The field experiment was conducted over a seven-week period. The measured outcome was the sales of the targeted healthy food products.

Results

The accessibility nudge significantly increased the sales of the fresh fruits. The impact of the salience nudge was limited presumably due to existing preferences or habits that typically facilitate bread purchases. As the sales of the yoghurt shakes remained consistently low over the seven-week period the impact of the social proof nudge remained unexamined. Critically, disclosing the purpose of the nudges did not interfere with effects.

Conclusions

Current findings suggest nudging as an effective strategy for healthy food promotion, and offer implications for topical debate regarding the ethics of nudges.

Healthy eating and restaurants. A review of recent evidence in the literature

Food environments influence food consumption and population health. This study sought to establish the outstanding themes in recent scientific literature about healthy eating and restaurants. Studies about the topic published from 2011 to 2016 in seven recognized databases were reviewed systematically. From 999 titles, 20 articles were selected. Content analysis through an inductive method by two independent investigators was performed using Nvivo 10.0. Three dominant subjects were identified: Food supply modifications, promotion of healthy choices and barriers against healthy eating promotion. The findings describe research opportunities in the area, particularly in the Latin American context. It is necessary to make interventions that result in healthy food environments given the impact on collective health.

Using Herbs and Spices to Increase Vegetable Intake Among Rural Adolescents

OBJECTIVE

To test whether adding herbs and spices to school lunch vegetables increases selection and intake compared with lightly salted control versions among rural adolescents.

DESIGN

This study compared intake of vegetables with herbs and spices with lightly salted controls (phase I) and tested whether 5 repeated exposures would increase students' intake of herb and spice seasoned vegetables (phase II).

PARTICIPANTS AND SETTING

A total of 600-700 students at a rural middle/high school (age 11-18 years).

INTERVENTION

In phase I, herbs and spices were added to 8 vegetables and outcomes were compared with 8 control recipes. In phase II, the impact of repeated exposure to herb and spice blends served on different vegetables was assessed.

MAIN OUTCOMES

Vegetable selection rates, weighed intake, and willingness to eat again.

ANALYSIS

Two-way ANOVAs tested effects of condition (herbs and spices vs control; before vs after exposure) and age (middle vs high school) on selection and intake.

RESULTS

In phase I, students ate more control than seasoned broccoli (P = .01), cauliflower (P = .006), and green beans (P = .01), and high schoolers generally consumed more seasoned vegetables than did middle schoolers (P < .03). In phase II, repeated exposure to herbs and spices increased reported willingness to eat again for seasoned broccoli (P = .003).

CONCLUSIONS AND IMPLICATIONS

In a short-term intervention, herbs and spices did not produce robust increases in school lunch vegetable intake among rural adolescents, but limited repeat exposure may increase students' willingness to consume these flavors. Additional work is needed to identify individual and school-level characteristics that affect students' willingness to select and consume vegetables with herbs and spices.

Can changing the position of online menu items increase selection of fruit and vegetable snacks? A cluster randomized trial within an online canteen ordering system in Australian primary schools

BACKGROUND

Manipulating the position of food items within the physical food environment has consistently been found to influence item selection. However, the extent to which this strategy is effective in an online food environment is unknown.

OBJECTIVE

This study investigated whether an intervention to position fruit and vegetable snack items as the first and last menu items in an online school canteen ordering system increased the selection of those items. It was hypothesized that at follow-up, a higher proportion of online lunch orders in intervention schools would contain the target items (fruit and vegetable snacks) in comparison to control schools.

DESIGN

Six primary schools in New South Wales, Australia, were recruited to a clustered randomized controlled trial conducted over an 8-wk period. Intervention schools received a redesigned menu where the target items were positioned first and last on the online menu. Control schools received no change to their online menu.

RESULTS

During the baseline period 1938 students (1203 intervention, 735 control) placed at least one online lunch order and were included in the study, with 16,109 orders placed throughout the study. There was no significant difference between groups over time in the proportion of orders that contained a "Fruit and Veggie Snack" item (OR = 1.136 [95% CI: 0.791, 1.632] P = 0.490).

CONCLUSIONS

Evidence from this large trial with robust study design and objectively collected data suggests that positioning fruit and vegetable snack items first and last within an online canteen menu does not increase the selection of these items. Further research is warranted to confirm this finding with other target menu items (e.g., treats) and across other purchasing contexts and online food ordering platforms. This trial was registered at the Australian New Zealand Clinical Trials Registry, http://www.anzctr.org.au/ as ACTRN12616001520426.

Make It Fresh, for Less! A Supermarket Meal Bundling and Electronic Reminder Intervention to Promote Healthy Purchases Among Families With Children

OBJECTIVE

To evaluate the effects of a supermarket meal bundling and electronic reminder intervention on food choices of families with children.

DESIGN

Quasi-experimental (meal bundling) and randomized, controlled trial (electronic reminders).

SETTING

Large supermarket in Maine during 40-week baseline and 16-week intervention periods in 2015-2016.

PARTICIPANTS

English-speaking adults living with at least 1 child aged ≤18 years (n = 300) with 25% of households participating in the Supplemental Nutrition Assistance Program.

INTERVENTION(S)

(1) Four bundles of ingredients needed to make 8 low-cost healthful meals were promoted in the store through displays and point-of-purchase messaging for 4 weeks each; (2) weekly electronic messages based on principles from behavioral psychology were sent to study participants reminding them to look for meal bundles in the store.

MAIN OUTCOME MEASURES

(1) Difference in storewide sales and individual purchases of bundled items (measured using supermarket loyalty card data) from baseline to intervention in intervention vs control groups.

ANALYSIS

Regressions controlling for total food spending and accounting for repeated measures.

RESULTS

There were no differences in spending on bundled items resulting from the meal bundling intervention or the electronic reminders.

CONCLUSIONS AND IMPLICATIONS

Overall, there was little impact of healthful meal bundles and electronic reminders on storewide sales or purchases of promoted items in a large supermarket.

Default-name and tasting nudges increase salsify soup choice without increasing overall soup choice

Nudging is a popular behavior change technique but the conditions for its effectiveness have not been researched extensively. The current study aimed to test whether the effectiveness of nudging is limited to certain characteristics of the nudged product by focusing on a specific product (salsify soup) within a broader category (soups). Two parallel studies were conducted in two sandwich restaurants in a university setting at which a default-name nudge ("suggestion of the chef") and a tasting nudge were implemented aimed at increasing the choice for salsify soup using a non-randomized study design during 10 and 12 measurement days. The beta-regression model showed that the default-name nudge increased the proportion of customers that choose the salsify soup during intervention days compared to non-intervention days, p < .001, OR: 1.70. The tasting nudge also increased the proportion of customers that choose the salsify soup from baseline to intervention, p < .001, OR: 6.17 and from baseline to post-intervention, p < .01, OR: 1.87, and decreased from intervention to post-intervention, p < .001, OR: 0.30. Both nudges did not increase the choice for the overall category of soups. The results show that certain types of nudges are able to increase specific products of a category without increasing overall choice of a category in contrast to previous findings.

A behavioural economics approach to improving healthy food selection among food pantry clients

OBJECTIVE

To test the effect of a behavioural economics intervention in two food pantries on the nutritional quality of foods available at the pantries and the foods selected by adults visiting food pantries.

DESIGN

An intervention (SuperShelf) was implemented in two food pantries (Sites A and B), with two other pantries (Sites C and D) serving as a control for pantry outcomes. The intervention aimed to increase the amount and variety of healthy foods (supply), as well as the appeal of healthy foods (demand) using behavioural economics strategies. Assessments included baseline and 4-month follow-up client surveys, client cart inventories, pantry inventories and environmental assessments. A fidelity score (range 0-100) was assigned to each intervention pantry to measure the degree of implementation. A Healthy Eating Index-2010 (HEI-2010) score (range 0-100) was generated for each client cart and pantry.

SETTING

Four Minnesota food pantries, USA.ParticipantsClients visiting intervention pantries before (n 71) and after (n 70) the intervention.

RESULTS

Fidelity scores differed by intervention site (Site A=82, Site B=51). At Site A, in adjusted models, client cart HEI-2010 scores increased on average by 11·8 points (P&lt;0·0001), whereas there was no change at Site B. HEI-2010 pantry environment scores increased in intervention pantries (Site A=8 points, Site B=19 points) and decreased slightly in control pantries (Site C=-4 points, Site D=-3 points).

CONCLUSIONS

When implemented as intended, SuperShelf has the potential to improve the nutritional quality of foods available to and selected by pantry clients.

Beyond Willpower: Strategies for Reducing Failures of Self-Control

Almost everyone struggles to act in their individual and collective best interests, particularly when doing so requires forgoing a more immediately enjoyable alternative. Other than exhorting decision makers to "do the right thing," what can policymakers do to reduce overeating, undersaving, procrastination, and other self-defeating behaviors that feel good now but generate larger delayed costs? In this review, we synthesize contemporary research on approaches to reducing failures of self-control. We distinguish between self-deployed and other-deployed strategies and, in addition, between situational and cognitive intervention targets. Collectively, the evidence from both psychological science and economics recommends psychologically informed policies for reducing failures of self-control.

'I've worked so hard, I deserve a snack in the worksite cafeteria': A focus group study

This study obtained insight in motivation regarding food choices of Dutch employees, especially when visiting the worksite cafeteria. We also aimed to know why employees visit the worksite cafeteria. These insights are useful for intervention development to encourage healthier purchases in worksite cafeterias. We conducted seven focus groups among 45 employees of seven Dutch companies. The topics were 1) drivers and motives for food selection; 2) motives for visiting the worksite cafeteria; 3) motives for food selection in the worksite cafeteria; 4) perceptions of healthiness of products in the worksite cafeteria and 5) solutions brought up by the employees to encourage healthier eating. Thematic analyses were conducted with MAXQDA software. Qualitative analyses revealed that this group of Dutch employees mentioned 'healthiness', 'price' and 'taste' as most important drivers food selection. These employees generally visit the worksite cafeteria to have a break from their work setting. Healthiness played a less important role in visiting or making food choices in the worksite cafeteria. Reasons for buying unhealthy food items were being tempted and the feeling to 'deserve' it. In order to choose healthier foods employees suggested a bigger offer of healthy food options, providing knowledge, changing prices and prominent placing of healthy foods. This focus group study shows that drivers for food selection can differ from motives for visiting the worksite cafeteria and when choosing food there. Health is important for food choice in general, but less important in the worksite cafeteria. The results of this study could be used in the development of strategies that aim to change people's food choice behavior.

Citizen approval of nudging interventions promoting healthy eating: the role of intrusiveness and trustworthiness

BACKGROUND

Nudging interventions have lately been widely adopted by policy makers to increase the welfare of society and to help citizens make better choices. Hence, it has become important to understand the conditions under which they are approved. While most research has looked into whether professionals approve of nudging interventions, surprisingly the opinion of the target group has been widely ignored. This study investigated citizens' level of approval of nudging in the realm of healthy eating promotion, as well as its boundary conditions.

METHODS

Participants (N = 1441) from the US and seven European countries were probed for their level of approval of nudges. Moreover, we investigated whether these levels of approval were dependent on the level of intrusiveness of the nudge and on the type and trustworthiness of the source (policy makers, experts, industry) implementing the nudge.

RESULTS

People revealed moderate to high levels of approval with nudging across all countries. Intrusiveness and nudging approval were negatively associated. Nudges implemented by experts received more approval than those by policy makers. In general, approval increased with the trustworthiness of the source.

CONCLUSIONS

These results provide information for European and American policy makers considering using nudging in their policy repertoire.